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:SS211GOV 3.11$ WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205-6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT Www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 8001 N Clements Rd cmazip <br />ceoss sreeer Comstock Rd APN 06516014 <br />OWNER NAME Reid Roberts <br />0 (h. P 4 • <br />PARCEL SIZE i 1-1 LAND USE APPLICATION # <br />PHONE <br />OWNER ADDRESS 11 South San Joaquin St uit 306 crryis-rxreziP Stockton, CA 95202 <br />CONTRACTOR Purviance Drillers, INC pHoNE 2 0 9-887-3 55 4 <br />CONTRACTOR ADDRESS P.O. Box 64 cmasTATEizipLinden CA 95236 <br />SUBCONTRACTOR/CONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CiTY/SrATFJZip <br />LICENSE `31 C-57 00-61 0 D-09 n Other NUMBER 377923 EXPIRATION DATE 7/31 /21 <br />BILUNG PARTY: OWNER 0 CONTRACTOR 0 SUBCONTRACTOFUCONSULTANT <br />Domes-no WELL SAMPLING: I:, General Mineral/Coliferm Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 'Irrigation/Agricultural C Indusbial 0 Water Quality Monitoring ii Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 0 New Well C Replacement Well C Well Alteration/Modification 0 Other <br />0 Monitoring Well(s) # of wells LI Soil Boring(s) dot borings 0 Geotechnical #ofborings <br />0 Out-Of-Service Well U Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump Pump Replacement b Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />, <br />Drilling Method Li Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic O Stainless Steel 0 Other <br />Grout Seal Depth ft D Neat Cement (9418 bag/5-10 gal water) 0 Sand Cement sack mixl7 gal water <br />0 Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant / Accelerator (name) <br />PEDESTAL Installed By u Driller 0 Pump Contractor 0 Other <br />E Concrete Pedestal ODimensions: Width ft Length <br /> <br />It Thick <br /> <br />in 0 Christy Box 0 Stove Pipe <br /> <br />1.Submersible 0 Turbine 0 Other HP Lc;13 Pump Set %WI ft Standing Water Level --1C4k ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE UCENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. <br />lMUM <br />SIGNEL <br /> <br />ADVANCE NOTICE REOLIIF,'ED FOR INSP0ONS - PLEASE CALL (209) 95,3-7807 <br />TITLE DATE <br /> <br />1\ <br />PUMP <br />de- <br />3of <br />N'52 <br />54" <br />Etohe4.441 <br /> PAYMENT <br /> RECEIVED <br /> /NOV' I 0 2020 <br />SAN JOAQUIN COUNTY <br /> YVIRONMENTAL <br />Hf:ALTH DEPARTMENT <br />DEPARTMENT ilS5 ONLY <br />Application Accepted By Date 11/P/07(06117 Area ,qC Employee ID# FR <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br /> <br />Date <br />Date 5117/2-0Z I <br />Date <br />LI SPECIAL Well Permit <br />n WAIVER Received <br />Constructed Well Depth <br /> <br />ft <br /> <br />PE <br />Codes <br />SC <br />Info <br />Received Checldfl <br />Cash <br />Amount <br />milted Date Permit/. <br />Service Request # Invoice # Well NV <br />1438./ OS'ID <br />1173 <br />/77 i SA' 1111040 LOP—W41L1‘)-(f <br />WELL /PUMP PERMIT